Important Prostate Cancer Advances of the Last 10 Years

Inspired by Prostate Cancer
Awareness Month (September),
I wondered what would be considered
the most noteworthy advance
in prostate cancer (PCa) management
in the past 10 years. The possibilities
are many, but certainly scientific and
therapeutic advances in metastatic
castration-resistant PCa that have
extended survival by 4–5 months
on average must figure large in my
analysis, given that PCa causes an
estimated 27,540 deaths annually. The therapeutics include sipuleucel-T
(a therapeutic vaccine) and radium-223, a first-in-class drug that targets
bone metastases with alpha particles, as well as abiraterone acetate,
enzalutamide, and cabazitaxel. Clinicians now have available an array
of therapeutic choices with which to manage a clinically challenging
group of patients.

Although using therapeutics to prolong life is a major goal of medicine,
I cannot ignore advances in the screening and management of
low-risk PCa that address the formidable challenge of decreasing
PCa overtreatment. Multiple randomized trials have shown that the
vast majority of prostate tumors have an indolent course, seldom
metastasizing and causing death. It became clear that many men with
low-risk PCa could safely avoid radical treatment without shortening
their lifespan. The result was the emergence of active surveillance as a
reasonable first-line management strategy for selected patients.

Today,
many institutions have protocols for monitoring patients for disease
progression, offering active treatment when appropriate. Guidelines
from the National Comprehensive Cancer Network recommend active
surveillance as the sole initial treatment for men with low-risk disease
and a life expectancy of less than 10 years and men with very-low-risk
disease and a life expectancy of less than 20 years. Guidelines from the
American Urological Association and European Association of Urology
also recommend that active surveillance be considered among the
first-line management approaches for clinically localized low-risk PCa.

Active surveillance has the potential to spare thousands of patients
the complications of radical surgery or radiotherapy (especially erectile dysfunction and urinary incontinence) that can adversely affect quality
of life. Although data suggest that active surveillance is underused, this
may change as confidence in this management strategy grows. Recent
studies may bolster that confidence. For example, some investigations
have identified biomarkers that can accurately distinguish between
indolent and aggressive tumors, which could assist in risk-stratifying
patients. Greater certainty of a tumor's indolence may translate into
more confidence in active surveillance as a management strategy.
New treatments that take patient care in a new and positive direction
are a great thing, but so are the medical advances that help patients
avoid jumping into treatment unless it is necessary.